An Evidence-Based Prehospital Guideline For External Hemorrhage Control

 

Here is a recent article enumerating acceptable guidelines for civilian-based, pre-hospital hemorrhage control. The authors reviewed existing literature and a predetermined methodology to established evidence-based criteria for the use of tourniquets and hemostatic dressings. Pay special attention to the recommended equipment (e.g., windlass tourniquets) and, more important, equipment they specifically recommend against (rubber band tourniquets).

http://informahealthcare.com/doi/pdf/10.3109/10903127.2014.896962

 

The High Price of Knowledge

A good article on the gains in medical knowledge harvested from this current conflicts:

http://healthaffairs.org/blog/2013/12/18/the-laboratory-of-war-how-military-trauma-care-advances-are-benefiting-soldiers-and-civilians/

The Laboratory Of War: How Military Trauma Care Advances Are Benefiting Soldiers And Civilians


December 18th, 2013

Editor’s note: This morning, in Bethesda MD, the Executive Director of the American College of Surgeons, Dr. David Hoyt, presented the leadership of Walter Reed National Military Medical Center with a plaque recognizing its designation as an ACS-certified Level II Trauma Center.  Walter Reed Bethesda is part of extraordinary chain of military health system facilities, providers, organizations, and techniques that have dramatically improved an injured service member’s odds of survival and recovery.  As the authors of this post note, lessons learned during more than a decade of war are now being adopted into civilian care, to the benefit of children and adults in every corner of the United States and beyond.  For more on emergency care, read the December Health Affairs issue, “The Future of Emergency Medicine: Challenges And Opportunities.

Out of the ashes of 9-11 and the two wars that followed, a new paradigm has emerged that has benefited more than 50,000 injured warfighters and is transforming civilian trauma care.  During the past decade of war, strategic investments in research and clinical care, coupled with contributions from world-class clinician-scientists, have produced the lowest case-fatality rate among combat casualties in the history of armed conflict.

At the beginning of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF), the combat injury case-fatality rate was approximately 18 percent.  Over the subsequent decade, it steadily decreased to 5 percent despite an overall increase in injury severity. This remarkable achievement is grounded in advances in all aspects of trauma care, from the point of injury to optimum treatment in military rehabilitation centers.

As with all previous conflicts throughout history, clinical knowledge generated in the civilian setting was rapidly adapted in innovative ways to address challenges encountered on the battlefield.  Now, it is coming full circle to improve the care and decrease the mortality of both injured warriors and civilian trauma victims. This reciprocal relationship between military and civilian medicine, recently highlighted in domestic terrorism attacks such as the Boston Marathon bombing and the mass shootings at Aurora and Tucson, is visible in daily practice in trauma centers throughout the country.

These improvements didn’t happen by accident; the military invested in relevant translational research and developed a flexible, evidence-based trauma system that rapidly developed, assessed, deployed, and refined new advances in trauma care and rehabilitation.  In this post we highlight a number of these advances and the science behind them, and we offer a roadmap to ensure that these advances are not only preserved for use in future conflicts, but evolve to benefit all patients — military and civilian alike.

What Has Been Accomplished

Tactical combat casualty careOne of the first important advances was recognition, based on experience gained in the First Gulf War, that combatants themselves are the true “first responders” on the battlefield. Combatants are trained to recognize and promptly respond to life-threatening injuries, and medics and corpsmen are now trained in a realistic, scenario-based, and standardized fashion, based on the principles of tactical combat casualty care (TCCC).  TCCC provides the training for the effective use of topical hemostatic agents (bandages with the ability to accelerate blood clotting) and, when necessary, tourniquets to control severe bleeding, along with other skills such as rapid assessment of injuries, airway control, treatment of traumatic pneumothorax (collapsed lung), and immediate pain control.

TCCC is divided into three phases that are relevant in both the combat and civilian mass casualty settings: care under fire, tactical field care, and tactical evacuation care.  “Tactical” refers to individual and small unit activities, such as direct care rendered by a first responder at the point of injury, in contrast to “operational” and “strategic” activities, which involve larger units and broader geographic space.  This coordinated approach achieved exceptional success; when adopted by elite units of the US military, it resulted in the near elimination of preventable deaths on the battlefield.  Today, civilian emergency medical systems (EMS) are adopting the TCCC approach using a course offered by national organizations representing the EMS community.

Bleeding control. Early hemorrhage (bleeding) control, using tourniquets and topical hemostatic agents, are a prime example of how new or improved techniques on the battlefield can produce profound benefits at home. Previously tourniquets were not advocated for routine use for fear of limb loss.  However, the need for tourniquets was quickly recognized as essential in modern warfare where severe extremity injuries are common and evacuation is often both timely and fast. Widespread adoption of tourniquets saved many lives in combat without secondary limb loss.4 As an adjunct, the use of topical hemostatics, was more than 90 percent effective. Over the course of the conflicts, these agents were modified several times.  This allowed military doctors to optimize their effectiveness while minimizing side effects.

Both of these approaches to hemorrhage have quickly made their way to civilian settings, moving “from the sandbox to the street.”  This was most clearly seen following the Boston Marathon bombings, where “without a doubt, tourniquets were a difference-maker and saved lives.

Massive transfusion protocols. Advances in care did not end on the battlefield; they accelerated upon arrival at hospital settings. This began with new approaches to replacing blood loss from trauma. Prior to our experience in Iraq and Afghanistan, the most severely injured casualties were resuscitated in a step-wise fashion, first with saline solutions, followed by a gradual escalation to the use of blood products. Faced with less than ideal outcomes, military surgeons challenged this approach and looked for better ways to replace blood loss. Based upon solid lab research, these surgeons introduced the concept of “balanced resuscitation”, by immediately countering blood loss with key components of blood when the injured soldier or marine’s injury profile suggested the need for massive transfusion (unstable patients or those with severe injury patterns). This approach not only improved survival, it reduced the rate of complications in combat-wounded patients.

Adoption of “massive transfusion protocols” has become one of the most swiftly adopted changes in care coming from the battlefield.  Today, a majority of Level I trauma centers in the US have shifted to this practice. This approach is also being adopted in surgical education, where trainees are taught to activate “massive transfusion protocols” to counter severe injuries.

“Damage control” surgery. The next major advance took place in the operating room where prompt surgical control of bleeding, closure of perforated bowel injuries, and early debridement of damaged tissue are key steps. Focusing on these priorities up front, leaving the abdomen “open” with temporary dressings, and deferring more complex definitive surgery for subsequent procedures has avoided the secondary insult of prolonged periods in the operating room.  This led to a practice called “damage control surgery.” This concept was first introduced in the civilian trauma world (utilizing a term adopted from the military, where “damage control” refers to maneuvers to save a ship so it can continue to be effective).  The technique caught on with military surgeons, many of whom who had trained in civilian trauma centers, and was swiftly refined under wartime conditions.  As with the other advances discussed, the widespread application of damage control surgery has benefited military and civilian populations alike.

Neurocritical care. Patients with specific injuries, most notably penetrating head and extremity injuries, have also benefited from military medicine.  In previous conflicts, many of these patients were assumed to have non-survivable injuries and were treated as “expectant” (i.e., only comfort care).  Now, they are aggressively managed using techniques similar to those applied in damage control surgery.

For example, in cases of massive head trauma, a portion of the skull is temporarily removed to allow the brain to swell without creating a lethal rise in pressure that would stop blood flow to the brain.  This is particularly important for patients faced with long medical evacuation times. Another technique involves preventing the spasm of major blood vessels that are necessary to support brain survival and function. Although this practice has not yet been widely adapted in civilian trauma, it may come to be widely used in future mass casualty events and conflicts.

Treatment of badly damaged limbs. Another advance that has seen widespread use is an integrated approach to early limb salvage versus amputation in patients suffering from massive extremity injuries with significant tissue loss and neurovascular damage. Military and civilian researchers have found that, for certain patients, early amputation results in better long-term functional outcome.  For patients who remain good candidates for limb salvage, the innovations in soft tissue reconstruction have produced survivors who not only recovered, but in many instances returned to full duty and extremely active lifestyles.

Two key adjuncts to the successful treatment of severe extremity wounds are adequate pain control and aggressive, early rehabilitation. The adoption of regional pain control and integrated pain management teams has allowed rehabilitation to start while the patient is still in the hospital.  All of these efforts come together in the treatment of the multi-limb amputees who face substantial challenges.  Without these approaches, the amazing functional results that have been seen would not be achievable.  Many of these techniques are now working their way into civilian practice, such as treatment of victims of the Boston Marathon bombings.

Rapid evacuation to tertiary care centers. Transporting injured personnel to centers capable of providing advanced levels of care required comparable innovations in tactical and strategic casualty evacuation.  In conflict zones, tactical evacuation is largely accomplished by medical evacuation helicopters, while inter-theatre strategic evacuation over thousands of miles is achieved with large Air Force fixed wing aircraft outfitted with ICU pallets and staffed by specially trained Critical Care Air Transport Teams (CCATTs).  This integrated approach has resulted in a reduced medical footprint in the conflict area as compared to previous conflicts.  Equally important, improvements in hand-offs of care were devised to assure seamless transitions between the military, the U.S. Public Health Service, the Veterans Health Administration, and, ultimately, civilian trauma and rehabilitation facilities. The collective impacts of these advances in care are unprecedented in military history.

How It Was Done

Almost as remarkable as this progress is the manner in which it was done.  Normally, progress in patient care is achieved through painstaking, incremental research, often tested and refined through large-scale randomized trials involving thousands of patients.  It’s been written that the average time frame for research to reach the bedside and be widely adopted into care is measured in decades.  The military health system didn’t have that sort of time. Lives depended on swift and sure decisions, backed by the best available evidence.

Much of the progress was made possible through creation of the Joint Trauma System (JTS), whose mission is to improve trauma care delivery across the continuum of care through careful data collection and analysis, to improve clinical outcomes in near real-time.  This effort represents the largest combat registry ever created.  In addition to monitoring the quality and outcomes of care, the JTS develops and implements clinical practice guidelines system-wide, and identifies the training and research needs for trauma care in the military.

The ability of the JTS to rapidly identify emerging injury patterns, develop best practices and research-based CPG’s, and subsequently disseminate and track such guidelines represents a paradigm shift away from costly, multi-year clinical studies to “focused empiricism” and continuous process improvement.  Driven to address challenges identified by the JTS, the DoD continues to invest in mission-relevant research focused on biomarker-based care, regenerative medicine, and advanced approaches to hemorrhage control.  While many civilian centers have adopted similar models with a degree of success, the widespread implementation of this approach could serve as a model for other large health care systems.

Early in what has proven to be the longest armed conflict fought by the U.S. to date, military medicine recognized that it needed to fundamentally change how it approached the care of wounded warriors.  It did this by implementing data-driven decisions at every step in the continuum of care, from battlefields in two nations across 8000 miles and three continents to world-class hospitals and rehabilitation centers in Germany and the United States.  Importantly, this work was done while the individuals involved were doing their utmost to provide the best possible care to every injured combatant and civilian they touched.  As was true following the conflicts in Korea and Vietnam, lessons learned in the crucible of war are beginning to transform care in civilian hospitals in the U.S. and around the world.

The progress that has been made over the past decade is tenuous at best.  Some of those who led these efforts have retired from the military, and others are struggling to contend with budget cuts, furloughs and funding constraints.  It won’t be easy to maintain surgical skills honed over a decade of conflict.  But this is essential to assure that military healthcare in any future conflict will be as good, and ideally better, than in the most recent ones. There is little doubt that thousands of service members and veterans are alive today thanks to the work of dedicated military and civilian health care professionals.  Many of the insights they developed are beginning to transform care in the civilian world and millions will benefit.

The knowledge gained over a decade of war cannot be taken for granted.  Continued work is needed to identify and manage challenges that are only faintly understood today.  The progress that is made will not only help our warfighters in future conflicts, it will help save the lives of civilians as well.

Needle Decompression Location Reviewed

We have discussed the changing thoughts regarding the sign and symptoms of Tension Pneumothorax in the past (see here: Rethinking Tension Pneumothorax). Although this study was broad, it did not address in detail the implications of different locations of one of the more popular treatments of tension pneumothorax: needle decompression. Due to an increased incidence of iatrogenic effects of improper needle placement, one of the recent topics of discussion among TCCC trainers has centered around locations (i.e., anterior vs lateral) of needle placement. Improper anterior placement in the mid-line direction can led to severe vascular injuries. Some have advocated for moving the primary location for needle insertion to the lateral location to mitigate iatrogenic effects. This location, however, raises other issues, specifically chest wall thickness in comparison to the anterior location, even as needles have increased in length.

A recent study published* in Academic Emergency Medicine seeks to answer one of the questions that have emerged from the debate by identifying the optimal site of needle insertion with respect to anterior wall thickness limitations. The results are interesting. Average chest wall thickness at the right side anterior second intercostal space, lateral forth and fifth mid-axillary locations were 46.4 mm, 53.8 mm and 63.7 mm, respectively. When considering the one factor of chest wall thickness as it relates to successful penetration of the plural space, the researchers concluded, the anterior location is superior. Furthermore, attempting to overcome the increased chest wall thickness at the lateral mid-axillary locations by using a longer catheter is risky, for it increases the risk of damaging surrounding vascular structures.

While this study does not address the larger issue of practitioners misplacement at the anterior location, it does illicit and attempt to answer an important question of impulsively changing training doctrine to emphasize the lateral location.

*Anterior Versus Lateral Needle Decompression of Tension Pneumothorax: Comparison by Computed Tomography Chest Wall Measurement by Sanchez, Leon, MD, MPH, et al. Academic Emergency Medicine 2011; 18:1022-1026 by the Society for Academic Emergency Medicine

Importance of Training Forward Life Saving Procedures and Future Blood Protocols

In a recent article published in the Journal of Trauma Injury, Infection, and Critical Care, the authors analyzed the effect of life-saving interventions (LSI) performed by combat medics and other forward providers. The medical practitioners in the study were arranged in an EMS style hierarchy under a medical director, with the majority of medics trained to the EMT-B level, in addition to supplemental training in TCCC-approved LSI procedures. Additionally, they analyzed outcomes with an eye toward the applicability of more advanced care in the form of Remote Damage Resuscitation protocols. As summarized below, they found that forward deployment of blood products would be beneficial if the logistical and scope-of-practice concerns could be addressed. In the limitations section of the study, they concede that certain biases might have affected the outcome. They note, for instance, “[t]he differential impact of transport time from point-of-injury to surgical facility arrival is worth considering.” Time from injury to point-of-injury treatment, time between request for evacuation to arrival of transportation, and time from extraction to the study facility all affected the outcomes, some of which were unknown in retrospect.

Although the authors did acknowledge in the conclusion that LSI need to be performed sooner, they unfortunately continued to argue that their notional blood protocol would have been beneficial. This is despite the fact that the majority of LSI were preformed by PA-level practitioners or higher, which is the major concern, because that indicates that urgent and priority patients were evacuated without LSI. It is difficult to surmise why LSI were not performed sooner, due to the nature of record keeping and retrospective studies. Perhaps tactical considerations dictated transport before treatment, or casualties deteriorated during evacuation. Nonetheless, early treatment is paramount, so training might possibly the more important to allocate resources to than blood protocols. Technology is an exceptional adjunct to the basics, but medics must have a foundation upon which to build.

Background: To analyze casualties from the Camp Eagle Study, focusing on
life-saving interventions (LSI) and potentially survivable deaths.

Methods: Retrospective cohort of battle casualties from a forward base engaged in urban combat in Central Iraq. Medical support included emergency medicine practitioners and combat medics with advanced training and protocols. LSI were defined as advanced airway, needle or tube thoracostomy, tourniquet, and hypotensive resuscitation with Hetastarch. Cases were assessed retrospectively for notional application of a Remote Damage Control Resuscitation protocol using blood products.

Results: Three hundred eighteen subjects were included. The case fatality rate was 7%. “Urgent” (55) or “priority” (88) medical evacuation was required for 45% of casualties. Sixty-one LSI were performed, in most cases by the physician or PA, with 80% on “urgent” and 9% on “priority” casualties, respectively. Among survivors requiring LSI, the percentage actually performed were airway 100%; thoracostomy 100%; tourniquet 100%; hetastarch 100%. Among nonsurvivors, these percentages were 78%, 50%, 100%, and 56%, respectively. Proximate causes of potentially survivable death were delays in airway placement and ventilation (40%), no thoracostomy (20%), and delayed evacuation
resulting in hemorrhagic shock (60%). The notional Remote Damage Control Resuscitation protocol would have been appropriate in 15% of “urgent” survivors
and in 26% of nonsurvivors.

Conclusion: LSI were required by most urgent casualties, and a lack or delay in their performance was associated with increased mortality. Forward deployment of blood components may represent the next addition to LSI if logistical and scope-of-practice issues can be overcome.

(J Trauma. 2011;71: S109–S113)

Rethinking Tension Pneumothorax

Rethinking Tension Pneumothorax

An interesting article in the Emergency Medicine Journal, “Tension Pneumothorax–Time for a Re-think?,” questions the traditional signs and symptoms of tension pneumothorax (TPT). The authors independently compiled and analyzed previous research dating from 1966 to 2003 determine if “classic” signs of TPT exist, and, if so, the rate of diagnosis. Essentially, the survey found that the majority of TPT cases do not present with classical signs, which necessitates a rethinking of how TPT recognition is taught (see Box 1). The authors also address the poor outcomes associated with needle decompression.

The article established that one must divide patients into two groups: 1) spontaneous breathing; 2) ventilated. This is important due to the ability of spontaneously breathing patients to compensate, thereby presenting differently. Group one displayed the ability to compensate during respiration with tension building (for a more detailed list of compensatory mechanisms, see Box 2). Up until time of death, cardiac output was reserved due to progressive tachycardia, incomplete transmission of positive IPP to the mediastinum (see Box 3 for group 1 signs and symptoms). Group two, however, presented differently due to not being able to compensate (see Box 4 and Table 1). Familiarity with the unique presentation of group 2 is obviously important because your patient may need to be ventilated en-route to a higher echelon of care.

The most intriguing findings were the poor correlation of TPT to mediastinal shift and tracheal deviation, two classic signs. The former is an inconsistent finding, except in children, due to mobility of their mediastinum. Moreover, tracheal displacement is also a poor indicator of mediastinal shift. In fact, in the this study, “it was absent in all 108 cases of suspected TPTs treated by paramedics with needle decompression and present in only 1 percent of those receiving needle decompression by flight nurses…. Even when present, the odds of experienced physicians diagnosing it are 50:50—that is, the same as tossing a coin.” Essentially, tracheal deviation is not diagnostic of TPT.

The authors also question the use of needle decompression as a diagnostic tool, due to associated morbidity (Box 8). For instance, “of 106 patients treated with tube thoracostomy by pre-hospital flight nurses, 38% had been attributable to failure of clinical improvement with needle decompression.” Furthermore, the authors are concerned with the use of needle decompression as a “rule-out” procedure, for no studies exist showing it as a sensitive test. Despite this, it is a therapeutic treatment and reduces time on scene when compared to chest tubes, which is important in the tactical environment. However, their research shows it is often used when no TPT is present, but that is an easier assessment after the fact. It should be highlighted that flutter valves, which are popular in the pre-hospital environment may cause re-tension according to their findings, so be vigilant in construction and re-assessment.

Overall, this is a detailed article that deserves consideration. It is worth your time to download the full version and prudently reassess your training and adjust accordingly.

References and tables from:
S Leigh-Smith and T Harris, “Tension Pneumothorax–Time for a Re-think?.” Emerg Med J 2005 22: 8-16.

Box 1
Box 2
Box 3
Box 4
Box 8
Table 1

Risks of Rubber Band Tourniquet Use

Rubber band tourniquets (RBT) have gained popularity in the law enforcement community over the past 24 months. The compact size and nominal cost make them attractive to cash-strapped, and over loaded with respect to equipment, LEOs. Furthermore, as LEO commanders seek to outfit their personnel with live saving equipment while grappling with budget constraints, RBTs seem like a viable option. However, upon further consideration, they may not be the BEST choice due to inherit dangers of RBTs with regard to function and application.

The function of RBTs is simple: one applies it proximal to the injury, wrapping it around the limb until hemorrhage control is achieved, using the elasticity of the rubber to create greater circumferential pressure with each wrap. Initially, this seems easy and straight forward. However, due to the nature of elastic wraps one must be cautious when using one as a tourniquet, due to the difficulty in controlling the applied pressure. As noted in the Journal of Medicine and Biomedical Research, “[t]he pressure induced by the rubber bandage increases at a rate of 3 to 4 times the initial pressure when the bandage is stretched after each wrap.”(1)(3) This is dangerous due to the shearing effect generated on the underling tissues, specifically the nerves. In fact, Graham et al found that at above 300mm Hg shearing forces increased exponentially.(2)(3) With RBTs this is concerning as “[t]he pressure applied to the limb could easily exceed the safe limits and put the limb at risk of complications because the rubber bandage is capable of generating pressures in excess of 1000mmHg beneath it.” “At such extremely high pressure,” Ogbemudia continues, “neurovascular damage becomes likely and makes the use of the RBT relatively unsafe.”(1)(3) He does explain how, in a controlled environment such as a surgical suite, a RBT can be made safe by placing a BP cuff under to monitor pressure. Obviously, this is not optimal in the tactical environment.

There are also difficulties faced when applying a RBT with respect to generating adequate circumferential pressure to stop arterial hemorrhage. Applying a RBT to an extremity, especially an upper limb, mobility is required in order to wrap it around the limb a sufficient number of times. If there has been any bone involvement, this may be an excruciating affair. Furthermore, if, due to pain associated with application, the casualty does not achieve hemorrhage control, he must then un-wrap the RBT multiple times, then re-wrap it in the hopes of achieving enough pressure. Unfortunately, the reverse is true. In an attempt to generate enough pressure, one may generate too much unknowingly. Compared to a windlass-style tourniquet, for instance, one must only turn the windlass an additional 180 degrees, thereby tightening it to achieve more tension. Tourniquets issued within DOD, unlike RBTs, are difficult to over tighten when used one-handed and according to the manufacturers’ directions due to the nature of the webbing and knot interface.

Finally, when compared to standard tourniquets used by the majority of DOD and many state and local LEOs, a RBT has multiple variables that must be considered that relate to the pressure generated. In this case, variables are defined as inconsistencies between casualties and application each time a tourniquets is used. They are compared as follows:

Windlass style tourniquets have 2 variables:
1) limb circumference;
2) degrees rotated.

RBT tourniquets have 4 variables:
1) the percentage of stretch applied with each turn (composition and elasticity of the material, which affect the restoring force of the polymers);
2) the number of layers of the RBT;
3) the degree of overlap;
4) the circumference of the limb.

In the end, a RBT can be used as a field tourniquet. However, it is not the best option for LEOs. The benefits of cost savings do not outweigh the potential problems and risks associated with rubber band tourniquets.

References
[1] Ogbemudia A et al. Adaptation of the rubber bandage for the safe use as tourniquet. Journal of Medicine and biomedical Research 2006; Vol. 5 No. 2 pp-69-74.
[2] Graham B et al. Perinerual pressures under the pneumatic tourniquet in the upper and lower extremity. Journal of Hand Surgery 1992: 17B: 262-6.
[3] McEwen J. A. and Casey V. Measurement of hazardous pressure levels and gradients produced on human limbs by non-pneumatic tourniquets. Accessd at
http://www.tourniquets.org/pdf/CMBEC%2032%20McEwen%20and%20Casey%20Tourniquet%20Paper.pdf

New Tactical Medical Book

We just received a copy of a new book covering the elements of tactical medicine. Check it out!

Tactical Medical Essentials Link

Managment of Suspected Spinal Injury In TCCC

A large discrepancy between civilian and military medicine exists with respect to the importance placed upon spinal injury management. In the past, most combat injuries have been secondary to penetrating trauma. Therefore, during the initial phases of treatment, moving the casualty to cover would be the only concern, without taking the time to immobilize c-spine as a civilian medic would. However, new injury patterns are emerging. As Dr. Keith Gates noted in the Spring 2010 issue of The Journal of Special Operations Medicine (JSOM), blunt trauma is emerging more often as an mechanism of injury secondary to the increase in number of IED attacks. According unpublished data, 39% of casualties had mechanism of injuries secondary to blunt trauma. Additionally, according to JSOM, between June and December 2009, of the 119 casualties with blunt force trauma spinal fractures, 14 had spinal cord injuries. Thus, an increasing number of casualties are presenting with thoracic and cervical injuries on the modern battlefield.

This trend has not gone unnoticed. A working group was commissioned to address this issue, out of which a new technique for spinal protection emerged, called Spinal Motion Restriction (SMR). Essentially, the rescuer would use the casualty’s IBA to protect the thoracic spine, while taking care to not unnecessarily manipulating the c-spine during movement. The suggested changes to the TCCC protocol are as follows:

Care Under Fire:
3. Direct casualty to move to cover and apply self-aid if able. If casualty requires assistance, move him to cover. If mechanism of injury included blunt trauma (such as riding in a vehicle which was struck by and Improvised Explosive Device), minimize spinal movement while extracting him from the vehicle and moving him to cover. The casualty should be moved along his long spinal axis if at all possible while attempting to stabilize the head and neck.

Tactical Field Care and TACEVAC Care Insert new #2:
Use Spinal Motion Restriction techniques as defined below for casualties whose mechanism of injury included blunt trauma IF: a) they are unconscious; b) they are conscious and have mid-line cervical spine tenderness or mid-line back pain; or c) they are conscious but demonstrate neurological injury such as inability to move their arms and/or legs, sensory deficits, or parenthesis. For these casualties, leave the IBA in place and secure to protect the thoracic spine. The cervical spine may be protected by using a cervical stabilization device in conjunction with the casualty’s IBA or by an additional first responder holding the casualty’s head to maintain alignment with the back. Long or short spine boards should be used in addition to these measures when available (JSOM, Spring 10, pg. 60).

Unfortunately, initial findings from a pilot study conducted at USAISR found that if one keeps the IBA in place, in a supine position, without the helmet, the c-spine is put in extension. More problems surfaced during later discussions: 1) pouches commonly worn on the IBA could further injuries in the supine position; 2) IBAs obstruct evaluation and treatment, thus they are often removed; 3) SMR may not be protective.

In the end, more research needs to be done in light of the recent trends in wounds. As more soldiers and LEO officers are exposed to blunt trauma, medics need to be conscious of the potentiality injuries secondary to it. While Spinal Motion Restriction is unsatisfactory, it continues the conversation regarding treatment.

What are your thoughts and experiences?

Update on Tactical Medicine Concepts and Controversies

We are pleased to announce an upcoming educational opportunity. On Thursday, October 14, 2010, the Texas Health Presbyterian Hospital will be hosting a conference titled, “Update on Tactical Medicine Concepts and Controversies.” This is a great opportunity and we will be attending.

Tactical_Medicine_Web_Brochure

Conference Description:
This conference will address those new and innovative interventions, products and techniques whose implementation at the point of wounding (POW) will allow for a more stable and viable patient upon arrival at the tertiary facility and, hence, improved longterm outcome. Though originally designed for the military theater, Tactical Combat
Casualty Care (TCCC) concepts are rapidly being adopted within the civilian medical and law enforcement communities as they are asked to respond to terror incidents at home. Columbine High School, Virginia Tech and terror incidents in Russia and India are only a few examples of the world in which we live. This conference is as relevant to
law enforcement (local and federal) and medical first responders as it is to the Soldiers and Marines on the battlefield. It is also relevant to physicians, nurses and other care providers, both civilian and military, who have a need for familiarity with current medical care techniques in the tactical environment.

Contest: 101 Ways to Use a Trianguler Bandage

In an age when hemostatic agents and pocket-sized BP cuffs monopolize most conversations regarding combat casualty care, a command of the basics is being lost. While the abundance of choices of pre-made kits addressing the majority of field-treatable injuries reduces the chance of needing to improvise, one ought to have a command of the basics using available materials.

A medic cannot have a more basic piece of kit than a triangular bandage. Therefore, we are having a contest to encourage submissions of different ways to use a triangular bandage to treat combat trauma. The details are as follows:

Prize: $200 in free Tac Med gear

Submission Format: Either submit a description to the comments section or email them to alan@tacmedsolutions.com. How-to videos are welcomed, but not required. We will be filming the most unique and helpful techniques for the blog.

Deadline: All submission must be in by 1 MAR 2010. We will announce the winner by 15 MAR 10. Due to concerns with operational anonymity, we will request your approval before sharing your name.